September 24, 2019

Short-term Health Plans Skimp on Medical Payments

A new report by the trade publication Modern Healthcare shows just how little short-term care plans spend on enrollees’ medical claims.

The report found that some plans spent as little as 9 cents of every premium dollar they collected on medical care.

The average paid out among the short-term plans analyzed in a report by the National Association of Insurance Commissioners was 39.2%. That’s a far cry from the 80% of premiums health plans are required to spend on medical care to comply with the Affordable Care Act.

The figures shine a harsh light on just how little short-term health plan policyholders benefit from the plans they purchase. 

The Trump administration issued regulations in 2018 that extended the amount of time someone can enroll in a short-term health plan to 12 months, and policyholders can renew coverage for a maximum of 36 months.

These plans do not have to comport with the ACA, like not covering 10 essential benefits and not having to cover pre-existing conditions – and they can even exclude coverage for medications.

2018 short-term health plan medical outlays*

Cambia Health Solutions: 9.3%
Spectrum Health: 36.1%
Genève Holdings: 36.2%
UnitedHealth Group: 37.3%
Medical Mutual of Ohio: 40.4%
Blue Cross and Blue Shield of SC: 44.2%
* As a percentage of premium charged

The above chart means that for every dollar collected in premium, the average short-term plan spent 39 cents on medical care for policyholders – with the rest spent on administration or kept as profit.

Short-term plans usually lack the consumer protections found in ACA-compliant plans and they have gaps in coverage that may not be readily apparent in marketing materials, which makes it difficult to compare plans and understand the full scope of coverage.

Importantly, as stated above, they are not required to and usually don’t cover the 10 essential health benefits that the ACA requires compliant plans to cover at no cost to the enrollee.

This scant coverage makes these plans much cheaper than ACA-compliant plans.

Here are some of the features of short-term plans that ACA-compliant plans are not permitted to offer:

Use health histories to determine who can get coverage – Applicants for short-term plans must often answer a health questionnaire used to screen out applicants with symptoms of an illness or condition – even if not yet diagnosed or treated. Some plans also exclude coverage for conditions for which medical advice, diagnosis, care or treatment was recommended or received in the prior 12 months.

Exclude key service categories from covered benefits – Few if any short-term plans cover maternity. Prescription drugs are not always covered, or they are only partially covered. Some plans exclude coverage for mental health, substance use disorder services, and tobacco cessation treatment.

No pre-existing conditions – Few short-term plans cover any pre-existing conditions. Typically, they cover only what’s listed in the Schedule of Benefits. If one of those is a pre-existing condition, it will likely have a cap of no more than $30,000. Also, insurers will often deny claims or cancel coverage for conditions they consider to be pre-existing.

Covered services limited – Many short-term plans have covered benefit limits like:

  • $1,000 per day for a hospital room and board
  • $1,250 a day for intensive care
  • $50 a day for doctor visits while in hospital
  • Total benefits are often capped at little more than $100,000 per year.

Renewal not guaranteed – Short-term plans will rarely guarantee renewal. If an enrollee suddenly develops a new health condition, the plan will likely not renew them.

August 8, 2019

The Costliest Claims for Catastrophic Conditions and the Drugs Used to Treat Them

A new report by Sun Life Insurance Co. highlights the top high-cost claim conditions that plague the U.S. health care system and account for more than half of all catastrophic or unpredictable claims costs.

The top 10 costliest claim conditions comprised over half (51.8%) of the $3 billion that Sun Life reimbursed to stop-loss policyholders from 2014 to 2017.

Stop-loss insurance (also known as excess insurance) is a product that provides protection against high-cost claims. It is purchased by employers that self-fund their own health plans, but do not want to assume 100% of the liability for losses arising from the plans.

The “2018 Stop-Loss Research Report,” which Sun Life has been publishing annually for the past six years, provides a glimpse into the kinds of claims that can have an outsized effect on both insured and self-insured employers’ health plans, and can drive overall expenditures.

Here are some of the other main highlights from the study:

  • Cancer treatment costs comprised 27% of all stop-loss claim reimbursements between 2014 and 2017.
  • The number of health plan enrollees that had claims costing more than $1 million increased by 87% during the four-year study period. In 2017, this group comprised 2.1% of claims but accounted for 20% of all stop-loss claims reimbursements.
  • The aggregate costs of injectable drugs that were part of claims that cost more than $1 million grew 80% from 2014 to 2017.

The most expensive catastrophic claims and the amounts Sun Life paid out in the aggregate between 2014 and 2017 are as follows:

  • Malignant neoplasm (cancer) – Total paid out: $564 million (a portion of total catastrophic claims: 19%)
  • Leukemia, lymphoma, and/or multiple myeloma (cancers) – $235 million (8%)
  • Chronic/end-stage renal disease (kidneys) – $153 million (5%)
  • Congenital anomalies (conditions present at birth) – $115 million (4%)
  • Transplant – $103 million (3.5%)
  • Septicemia (infection) – $88.5 million (3%)
  • Complications of surgical and medical care – $78 million (2.5%)
  • Disorders relating to short gestation and low birth weight (premature birth) – $74 million (2.5%)
  • Liveborn (short gestation/low birth rate, and congenital anomalies) – $69 million (2%)
  • Hemophilia/bleeding disorder – $68 million (2%)

Injectable drug costs

Injectable drugs (which include those delivered by IV or that are self-administered injectable medications) accounted for 8.5% of the total paid out for high-cost claims.

But that’s just the average for the four-year period. Injectable drugs are accounting for a greater share of overall catastrophic claims costs, reaching 9.3% in 2017.

In 2017 alone, 418 drugs contributed to the total $186.3 million that was spent on injectable medications for high-cost claims. But, 62% (or $114.7 million) of the cost was attributed to the top 20. The top five medications accounted for nearly 30%.

Please note that the injectable drugs on the high-cost list are there for different reasons. Some are on the list because of the frequency (how often they are used and how many patients are given the drugs) that they are administered, and others are there because their cost is extremely high.

As an example, the report points to the two top injectable treatments – cancer drugs Yervoy and Neulasta.

Neulasta (used to reduce the chance of infection in patients undergoing chemotherapy) was administered to 354 patients and cost on average $33,800 per dose.

On the other hand, Yervoy, used to treat melanoma that has spread or cannot be removed by surgery, was administered to just 43 patients, but the cost per dose was $323,000.